Healthcare Provider Details

I. General information

NPI: 1023990942
Provider Name (Legal Business Name): MAXINE ABELLANOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35320 DAGGETT YERMO RD
YERMO CA
92398-0408
US

IV. Provider business mailing address

20821 US HIGHWAY 18
APPLE VALLEY CA
92307-3549
US

V. Phone/Fax

Practice location:
  • Phone: 760-514-6888
  • Fax:
Mailing address:
  • Phone: 909-215-8065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number210050499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: